5. Consider alternatives to indwelling catheters including condom catheters or in and out catheterization, where appropriate.

What are the conclusions of clinical trials and meta-analyses regarding the control of catheter-related UTIs (Urinary Tract Infections)?

1. In a Cochrane review, Niël-Weise et al found that there is evidence that suprapubic catheters have advantages over indwelling catheters in respect of bacteriuria, recatheterization and discomfort. The clinical significance of bacteriuria was uncertain, however, and there was no information about possible complications or adverse effects during catheter insertion. The review also revealed more limited evidence that the use of intermittent catheterization was also associated with a lower risk of bacteriuria than indwelling urethral catheterization, but might be more costly. Using intermittent catheterization postoperatively limits catheterization to those people who definitely need it.

2. A Cochrane review in 2006 was aimed at establishing the optimal way to manage urinary catheters following urogenital surgery in adults in order to minimize complications. Despite reviewing 39 eligible trials, few firm conclusions could be reached due to study limitations. Whether or not to use a particular policy is usually a trade-off between the risks of morbidity (especially infection) and risks of recatheterization.

3. A Cochrane review in 2005 evaluated whether certain antibiotic policies are better than others in terms of prevention of urinary tract infections. The authors concluded that there was weak evidence that antibiotic prophylaxis reduced the rate of UTI in female patients with abdominal surgery and a urethral catheter for 24 hours. There was limited evidence that receiving antibiotics during the first three postoperative days or from postoperative day two until catheter removal decreased the rate of bacteriuria in surgical patients with indwelling catheters for at least 24 hours postoperatively. There was also limited evidence that prophylactic antibiotics reduced bacteriuria in non-surgical patients.

4. A prospective, randomized comparative trial reported that the use of external condom catheter drainage for men compared with a short-term indwelling urethral catheter reduced acquisition of bacteriuria and adverse outcomes and was more acceptable to the patient.

5. A randomized study reported that in-and-out catheterization was as effective as the use of an indwelling catheter for management of postoperative retention.

6. A randomized, controlled trial comparing suprapubic and urethral catheterization for men undergoing elective laparotomy reported a similar incidence of urinary infection in the 2 groups. Current evidence is not sufficient to support the routine use of a suprapubic catheter for short-term catheterization to prevent symptomatic urinary infection or other complications.

What are the consequences of ignoring the prevention and control of catheter-related UTIs (Urinary Tract Infections)?

The consequences of ignoring concepts related to catheter-related urinary tract infection (CRUTI) prevention are numerous and include patient morbidity, mortality, discomfort, and financial cost. Some of the most common complications of CRUTI include cystitis, pyelonephritis, gram-negative bacteremia, prostatitis, epididymitis, and orchitis in males. Less commonly, patients may develop septic arthritis, endocarditis, vertebral osteomyelitis, meningitis, and endophthalmitis. These potentially preventable complications lead to prolonged hospital stay and tremendous financial costs (see "role and impact" below). It is estimated that each episode of CRUTI costs at least $600, and each episode of urinary tract–related bacteremia costs at least $2800. Furthermore, the Centers for Medicare and Medicaid Services mandate on preventing hospital acquired conditions has included CRUTI as one of the ten categories that Medicare will no longer offer reimbursement for treatment. The mortality associated with CRUTI is quite alarming. Each year, CRUTIs lead to more than 13,000 deaths.

Summary of current controversies.

Prophylactic antibiotics in patients with urinary catheters - A cochrane review by Niël-Weise et al found weak evidence that antibiotic prophylaxis compared to giving antibiotics when clinically indicated reduced the rate of symptomatic urinary tract infection in female patients with abdominal surgery and a urethral catheter for 24 hours. There was no evidence regarding the rates of allergic reactions or other side effects from the antibiotics, nor about the chance of developing bacteria with antibiotic resistance. Currently, routine antibiotic prophylaxis in patients with urinary catheters is not recommended.

Antiseptic or antimicrobial-impregnated catheters - The CDC reports antimicrobial-impregnated catheters (such as silver-alloy coated catheters), may decrease the risk of Catheter-related UTI. However, current data on the clinical benefit of such devices are also limited. CDC recommendations state that antimicrobial/antiseptic-impregnated catheters should be considered only if the CRUTI rate in a facility is not decreasing despite implementing and documenting adherence to the core strategies to reduce the risk of CRUTI. Certain high-risk patients may also benefit from these catheters, but more research is needed.

Screening catheterized patients for asymptomatic bacteriuria - Routine screening of catheterized patients for ASB is not recommended. Such screening may be warranted in certain clinical situations.

What is the impact of catheter-related UTIs (Urinary Tract Infections), and what is the need for control relative to infections at other sites or from other specific pathogens?

Urinary catheters are ubiquitous in nearly all health care settings, but they are most often used in acute care hospitals (including ICUs); long-term care facilities; and in persons with injured spinal cords. At some point in their hospital stay, 12-16% of hospital inpatients will have a urinary catheter placed. With their common use, come significant morbidity, mortality, and cost. Catheter-related UTI is the most common healthcare–associated infection (HAI) in the United States and worldwide. In the United States, UTI accounts for 40% of all HAI's with the majority of infections (80%) resulting from an indwelling urinary catheter. Indeed, in catheterized patients, the daily risk of acquiring a UTI varies from 3% to 10%. Even when comorbid conditions and other factors are accounted for, the data suggest that catheter-related infection portends a nearly threefold increased risk of dying.[16] In the United States alone, more than 13,000 deaths per year are linked to CRUTI.

Not to be overlooked, the financial burden of CRUTI is immense. In 2007, Klevens et al estimated the incidence and financial impact of the top five healthcare associated infections in the Unites States. There were approximately 450,000 CRUTI's; which was over 1.5 times greater than the next most common HAI, surgical site infections (see Table II).

Table II.

Average attributable per patient costs of HAI by selected sites of infection (low estimate)

SSI

$11,087

CLABSI

$6,461

VAP

$14,816

CR-UTI

$749

CDI

$5,682

The CDC has estimated the average attributable per patient costs of HAI's by selected sites of infection and reports that Catheter-related UTI has the lowest cost in comparison to the other most common sites of HAI (see Table III). However, CRUTI is by far the most common HAI, further illustrating the importance of sound infection control methods to curtail this burden. Without adjusting for inflation, estimates from one university hospital (based on data approximately 20 years ago) were that hospital-acquired UTI led to about $204,000 in additional expenses per year. It is important to note that while CRUTI's represent the greatest burden comparatively among HAI's, they provide the greatest opportunity for improvement. Simply limiting unnecessary catheter use and, when indicated, limiting duration of use would likely have a dramatic impact on CRUTI rates.

Table III.

Estimated number of HAI's by site of infection

Major site of Infection

Estimated Number of Infections

Healthcare-Associated Infection (all HAI)

1,737,125

Surgical Site Infection (SSI)

290,485

Central Line Associated Bloodstream Infections (CLABSI)

92,011

Ventilator-associated Pneumonia (VAP)

52,543

Catheter-related Urinary tract Infection (CR-UTI)

449,334

Clostridium difficile-associated disease (CDI)

178,000

What national and international catheter-related UTIs (Urinary Tract Infections) guidelines exist?

What other consensus group statements exist, and what do key leaders advise?

There are numerous guidelines regarding the prevention of CRUTI. The most important common thread in these guidelines can be summarized in the following CDC recommendation: "The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter. Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed." The SHEA/IDSA consensus guidelines echo this recommendation stating; "The duration of catheterization is the most important risk factor for development of infection. Limiting catheter use and, when a catheter is indicated, minimizing the duration the catheter remains in situ are primary strategies for CAUTI prevention.". The SHEA/IDSA consensus guidelines also contain a summary of the evidence-based recommendations from published guidelines. (See Table IV).

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